[The AOSpine Classification of Thoraco-Lumbar Spine Injuries]. / Die AOSpine-Klassifikation thorakolumbaler Wirbelsäulenverletzungen.

Optimal treatment of injuries to the thoracolumbar spine is based on a detailed analysis of instability, as indicated by injury morphology and neurological status, together with significant modifying factors. A classification system helps to structure this analysis and should also provide guidance for treatment. Existing classification systems, such as the Magerl classification, are complex and do not include the neurological status, while the TLICS system has been accused of over-simplifying the influence of fracture morphology and instability. The AOSpine classification group has developed a new classification system, based mainly upon the Magerl and TLICS classifications, and with the aim of overcoming these drawbacks. This differentiates three main types of injury: Type A lesions are compression lesions to the anterior column; Type B lesions are distraction lesions of either the anterior or the posterior column; Type C lesions are translationally unstable lesions. Type A and B lesions are split into subgroups. The neurological damage is graded in 5 steps, ranging from a transient neurological deficit to complete spinal cord injury. Additional modifiers describe disorders which affect treatment strategy, such as osteoporosis or ankylosing diseases. Evaluations of intra- and inter-observer reliability have been very promising and encourage the introduction of this AOSpine classification of thoracolumbar injuries to the German speaking community.

History of neurosurgical techniques in head injury.

The techniques of surgery for head injury have evolved from an emphasis on exploration for diagnosis to a focus on decompression, maintenance of adequate perfusion, restoration of anatomic integrity, prevention of complications, and preservation of cosmesis.

Prognostic factors in the occurrence of posttraumatic epilepsy after penetrating head injury suffered during military service.

In this retrospective study, the authors evaluated confounding risk factors, which are allegedly influential in causing unprovoked posttraumatic epilepsy, in 489 patients from the frontlines of the Iran-Iraq War. Four hundred eighty-nine patients were followed for 6 to154 months (mean 39.4 months, median 23 months), and important factors precipitating posttraumatic epilepsy were evaluated using uni- and multivariate regression analysis. One hundred fifty-seven (32%) of 489 patients became epileptic during the study period. The results of univariate analysis indicated a significant relationship between epilepsy and Glasgow Outcome Scale (GOS) score (X2 = 76.49, p < 0.0001, df = 2), Glasgow Coma Scale score at admission (X2 = 19.48, p < 0.0001, df = 3), motor deficit (X2 = 11.79, p < 0.001, df = 1), mode of injury (X2 = 10.731, p < 0.05), transventricular injury (X2 = 6.9, p < 0.008, df = 1), dysphasia (X2 = 5.3, p < 0.02), central nervous system infections (X2 = 5.3, p < 0.02), and early-onset seizures (X2 = 4.1, p < 0.04, df = 1). The results of multivariate analysis, on the other hand, indicated that the GOS score and motor deficit were of greater statistical importance (X2 = 35.24, p < 0.0001; and X2 = 7.1, p < 0.07, respectively). Factors that did have much statistically significant bearing on posttraumatic epilepsy were the projectile type, site of injury on the skull, patient age, number of affected lobes, related hemorrhagic complications, and retained metallic or bone fragments. Glasgow Outcome Scale score and focal motor neurological deficit are of particular importance in predicting posttraumatic epilepsy after missile head injury.

Visual failure caused by suprasellar extramedullary hematopoiesis in beta thalassemia: case report.

OBJECTIVE AND IMPORTANCE: Small deposits of extramedullary hematopoiesis, acting as epileptogenic foci, have been observed near convexity dura and adjacent to falx cerebri. These foci could potentially grow and act as space-occupying lesions, producing focal neurological deficits. This condition was observed in a unique case of thalassemia major, with progressive visual loss caused by extramedullary hematopoiesis originating from the base of the cranium and extending up to the inferior third ventricle. The patient had been operated on 4 years earlier to relieve the compressive effects of ectopic marrow in the thoracolumbar epidural space. CLINICAL PRESENTATION: A 21-year-old man is reported with progressive visual loss caused by compressive optic neuropathy as a result of extramedullary hematopoiesis. Computed tomography of the head revealed a suprasellar and parasellar enhancing mass originating from the pre-sphenoid cranial base and approaching the lower third ventricle. INTERVENTION: Partial resection of the tumor was accomplished by a transsphenoidal approach. Monthly blood transfusions and low-dose radiotherapy of the appropriate anatomic structures were then performed. The patient's visual acuity improved only modestly. CONCLUSION: Extramedullary hematopoiesis, although extremely rare, could arise from the base of the cranium and act as a parasellar tumor. When any patient with thalassemia major requiring multiple transfusions develops visual failure, appropriate studies should be performed to rule out compression of visual pathways by ectopic marrow, especially if the patient is receiving deferoxamine.

Central nervous system infections after military missile head wounds.

OBJECTIVES: To evaluate variables instrumental in central nervous system infections after military missile head wounds, using uni- and multivariate analysis in 964 patients during the 8-year Iran-Iraq War. METHODS: Factors considered in this retrospective study were: the types of projectile, mode of injury, paranasal sinus involvement, number of lobes involved, transventricular injuries, place of exploration (base hospital or Nemazee Hospital), cerebrospinal fluid (CSF) fistulas, Glasgow Coma Scale (GCS) score, retained bone, and retained shell fragments. RESULTS: During the study period, 105 patients (11%) developed central nervous system infections, including 20 abscesses, 1 case of cerebritis, 2 cases of fungus cerebri, and 82 cases of meningitis. gram-negative organisms, especially Klebsiella pneumoniae, were the most frequent offending organisms. Forty-one percent of the 133 deaths were due to infections, but the death rate from infection was only 4.4%. Univariate analysis showed mode of injury, number of lobes involved, ventricular penetration, paranasal sinus involvement, CSF fistulas, place of exploration, GCS score, and retained bone fragments to have significant bearing on the incidence of central nervous system infections. On the other hand, multivariate regression analysis disclosed the following factors each enhancing infection: CSF fistulas (chi2 = 46.526), transventricular injuries (chi2 = 13.4790), and paranasal petrous sinuses involvement (chi2 = 4.2221). When compared with primary exploration at the Nemazee Hospital, both exploration at a base hospital and no exploration at all were associated with increased chances of infection (chi2 = 4.7629 and 8.3220, respectively). Additionally, when tangential, crossed penetrating, and uncrossed penetrating injuries were compared with through-and-through injuries, the uncrossed penetrating mode was associated with less infection (chi2 = 0.1652, 2.6353, and 5.0817, respectively). Only two patients were readmitted for new evidence of infection 3 and 5 months after missile head wounds, one definitely due to and the other on suspicion of CSF fistulas. One hundred and thirty-seven of 587 patients with retained bone fragments were followed a mean of 42 months with no evidence of delayed infection. CONCLUSION: In this study, CSF fistulas and transventricular and paranasal sinus injuries all were associated with increased chances of central nervous system infections after military missile head wounds. Infection rate was lower in penetrating injuries not crossing into another dural compartment. Exploration at the Nemazee Hospital, despite delays in evacuation, had less incidence of infection than surgery at a base hospital within the first 24 hours of injury. Retained bone and metal fragments, a lower GCS score at the time of admission, secondary exploration at the Nemazee Hospital, and number of lobes involved were less important when evaluated in a multivariate regression model.

Comparative study of functional recovery for surgically explored and conservatively managed spinal cord missile injuries.

OBJECTIVE: In a retrospective study, the extent of functional recovery and the merits of surgical exploration versus conservative management for spinal cord injuries were evaluated for 145 casualties from the front lines of the Iran-Iraq conflict. METHODS: Eighty-seven patients who underwent surgical exploration and 58 patients who were conservatively treated were monitored for 6 to 140 months (average, 57 +/- 31 mo) for any changes from their baseline neurological status, using the Frankel Scoring System. RESULTS: Twenty-two of 90 patients (24.4%) with complete injuries (Frankel score A) and 53 of 55 (96.4%) with incomplete injuries (Frankel scores B, C, and D) experienced changes in their neurological status as they recovered. Improvement was noted for 42 of 87 surgically treated patients (13 of 55 with complete injuries and 29 of 32 with incomplete injuries). Among conservatively treated patients, improvement was noted for 32 of 58 (55%), including 25.7% of those with complete injuries and 100% of those with incomplete injuries. Independent walking (Frankel scores D and E) was achieved by 10 of 90 patients with complete injuries and by 52 of 55 patients with incomplete injuries. Surgery did not affect the final outcome. Thirteen of 17 (76%) cerebrospinal fluid fistulas, 13 of 15 (87%) meningitides, and 4 of 6 (67%) local septic complications were encountered in the surgically treated group. CONCLUSION: Surgery did not enhance functional recovery from spinal cord missile injuries but did correlate with an increased prevalence of complications (fistulas, meningitis, and local sepsis). With or without surgical exploration, patients with seemingly complete cauda equina injuries demonstrated better functional outcome than did those with spinal cord injuries.

Management of traumatic aneurysms caused by high-velocity missile head wounds.

Trauma is implicated as a significant factor in the genesis of fewer than 1% of intracranial aneurysms. With the introduction of powerful neuroimaging technology, slowly but definitely, predictive variables are being added to solve this seemingly deadly pathology resulting from projectile injuries of the brain. This article discusses recent literature, nonprojectile penetrating traumatic aneurysms, iatrogenically induced traumatic aneurysms, materials and methods, traumatic aneurysms, and results.

Neurosurgical approaches to cerebrospinal fluid rhinorrhea.

The evolutionary concepts of pinpointing and treating cerebrospinal fluid (CSF) fistulas over the past few decades are reviewed taking into consideration the dynamic character of CSF circulation. The localization of the site of leakage is greatly facilitated by the judicious use of a variety of radioisotope and radiological techniques. The most recent are Metrizamide CT Cisternography and Magnetic Resonance Imaging. It is asserted that still the most challenging cases are those with intermittent liquorrheas, and those patients in which the site of the fistula is not easily defined. The authors will describe their personal experience with intracranial surgical repair of fistulas located in the anterior fossa.

The value of intraoperative scans during CT-guided stereotactic procedures.

The accuracy stereotactic procedures performed during the pre-computed tomography (CT) era was confirmed by intraoperative X-ray pictures. With the availability of CT it is now possible to confirm the position of the probe-tip on an image of the target. For biopsy of small lesions in critical areas of the brain, permanent placement of radioactive seeds, or thalamotomy, it would be desirable to have confirmation of the site of the probe-tip prior to performing the main step of the procedure. Intraoperative CT was performed in 216 stereotactic procedures carried out on the scanner table including biopsies, aspiration of cysts, brachytherapy, aspiration of abscesses, thalamotomy, and evacuation of intracerebral hematoma. In 6 cases, inaccuracies were detected, which it was possible to correct so as to place the probe where desired.

Stereotactic approach to skull-base lesions.

With improved knowledge of the anatomy and increased collaboration between the neurosurgeon and the otolaryngologist, successful surgical resection of skull-based tumors is being achieved with reduced mortality and morbidity. In spite of this, there remains a group of patients in whom an alternate surgical approach of stereotaxis may be indicated. This group of patients includes those in whom only biopsy is required, or those in whom brachytherapy using high-intensity (125)I is planned because the patients' general condition is not good enough to undergo open surgical resection of the tumor or the tumor is unresectable or the patient refuses open surgery. This article presents a preliminary report on stereotactic approach to skull base lesions with special emphasis on the technique.

Surgical outcome in 435 patients who sustained missile head wounds during the Iran-Iraq War.

Variables important in predicting the final postsurgical outcome of 435 patients who sustained missile head wounds during the Iran-Iraq War were evaluated over a 99-month period. The type of projectile, site of injury, and presence or absence of foreign material did not seem to have a significant effect on the final outcome. Of the patients with a perforating type of injury, 48.8% had a poor surgical outcome as compared with 19.9% with a penetrating type and 15.6% with a tangential type. This difference is statistically significant (chi 2 = 14.7 and 17.1, respectively; p less than 0.001). The most important factor in predicting overall outcome was the Glasgow Coma Scale (GCS) score at the time of admission. Mortality and morbidity contributing to a poor surgical outcome were noted in only 6% of patients with a GCS score at admission of 13 to 15, in 24.6% of those with a GCS score of 9 to 12, in 57% of those with a GCS score of 6 to 8, and in 65% of those with a GCS score of 3 to 5. Of the 71 patients who died, 75% had a score of 3 to 8. Perforating projectiles or those traversing two or more dural compartments were statistically significant in contributing to mortality and morbidity (chi 2 = 17.2; p less than 0.001). The incidence of focal neurological deficit was 100, 90.6, 88, and 52.2% in patients with GCS scores of 3 to 5, 6 to 8, 9 to 12, and 13 to 15, respectively. The two best predictors of mortality in this group of patients were a low GCS score and infection.

Causes of infections in penetrating head wounds in the Iran-Iraq War.

Factors seemingly influential in postoperative central nervous system infections were evaluated in 379 patients who sustained missile wounds to the head during the Iran-Iraq War. The mean wound age was 49 hours. The site of injury and presence of retained bone and/or shell fragments did not have a significant effect on infection rate. Thirty-three of 379 patients developed cerebrospinal fluid (CSF) fistulas of which 12 (36%) were associated with infection. The infection rate was 6 of 346 (1.7%) in the absence of CSF leaks. There was a statistically significant association between CSF fistula and infection. All 6 positive cultures in patients with CSF fistulas were gram-negative. Thirty-two patients died during the study, a mortality rate of 8.4%. The mortality rate from infection was 1.8%. Two hundred seventy-seven of 347 patients were followed for a mean of 22 +/- 17 months during which time 2 patients were readmitted with central nervous system infections, both due to CSF leakage. CSF fistulas were the main predisposing factor in postdebridement central nervous system infections in this study.

Traumatic aneurysms of brain due to high velocity missile head wounds.

Two hundred twenty-three of 255 consecutive patients underwent cerebral angiography 16.9 +/- 11.6 days (SD) after high velocity missile injury to the head over a 29-month study period. Shell fragments were the most frequent projectiles (73.7%), and penetrating wounds were the most frequent injuries (61%). During the study, 2 patients (1 with an ophthalmic and the other with an anterior cerebral artery aneurysm) presented with delayed traumatic intracerebral hematoma; the first patient had had negative angiography 90 days earlier, and the second patient was admitted from a rehabilitation center after operation in another center 25 days earlier for a penetrating left frontal shell fragment injury. Six of 223 patients (2.7%) had dormant aneurysms (4 middle and 2 anterior cerebral arteries). Seven of 8 patients were operated on again to exclude their aneurysms from the cerebral circulation. Two of 8 patients died postoperatively (1 within 24 hours and another 51 days after discharge from the hospital in a vegetative state). Fragments penetrating temporal, temporoparietal, or pterional areas had a significantly greater chance of causing arterial injury (chi 2 = 11.46, P less than 0.001). There was a significant chance of having an aneurysm if a hematoma was seen at operation or on computed tomography of the head (chi 2 = 4.18, P less than 0.05). The penetrating mode of injury and shell fragments crossing the midline were two variables for which the statistical significance had a P value of 0.08. It is concluded that war casualties with penetrating shell fragment injuries near the pterion, especially when harboring intracerebral hematomas, should undergo cerebral angiography to rule out vascular injuries of the brain.

Comparative study of bacteriological contamination between primary and secondary exploration of missile head wounds.

Aerobic and anaerobic bacterial contamination of scalp wounds, indriven bone fragments, and brain tracks were studied in two groups (A and B) of nonrandomized patients with missile head wounds in a 20-month study of patients from the front lines of the Iran-Iraq war. In the 53 Group B patients, the primary debridements, most of which had been performed within 24 hours after injury, were deemed insufficient and a secondary definitive exploration was performed. Group A patients (62) had primary definitive explorations at Nemazee Hospital after a mean of 66.5 hours since injury. All of the patients had been started on dexamethasone and a combination of either ampicillin and chloramphenicol or crystalline penicillin G and chloramphenicol after field evacuation. The contamination rate of scalp wounds, bone fragments and brain tracks was slightly higher in Group A (38.4%, 22.2%, and 29.6% respectively, for Group A and 31.9%, 19.5%, and 27% for Group B, respectively). Staphylococcus albus among the gram-positive and Acinetobacter among gram-negative bacteria were the most common infecting organisms. Fifty per cent of the bacteria cultured from the brain tracks of Group A and 30.8% of those cultured from Group B patients were gram-negative. A total of 125 patients in four groups was included in our overall study of victims of missile wounds that violated the dura mater. Four patients developed meningitis at Nemazee Hospital (3 postoperatively and 1 after facial penetration). Two patients in Group B were admitted with meningitis (1 with an accompanying abscess), 1 of them 20 days and the other 60 days after exploration at two different centers.(ABSTRACT TRUNCATED AT 250 WORDS)

Intradural extramedullary spinal metastasis. A report of 10 cases.

The management of 10 patients with symptomatic localized intradural extramedullary spinal metastasis is reviewed. The single most common primary source was carcinoma of the breast (four cases). The initial symptom in nine patients was pain, with five patients reporting a characteristically severe cramping discomfort with radicular distribution. All patients underwent laminectomy decompression. At the time of surgery, six of the patients were weak but ambulatory and four were bedridden. Following surgery, four patients enjoyed some measure of pain relief, seven patients became ambulatory, and three remained bedridden. Two patients achieved a "satisfactory" result, and were walking and continent 6 months after surgery. Secondary brain tumors were demonstrated or implicated in nine patients, supporting the concept that the spinal metastases represented tertiary deposits following dissemination via the cerebrospinal fluid. Symptomatic intradural extramedullary spinal metastasis causes a virulent clinical syndrome with poor prognosis and disappointing outcome after treatment. Given the high incidence of associated cerebral metastatic involvement, total neuraxis radiation and/or chemotherapy should be considered when symptomatic spinal metastasis is discovered to be intradural and extramedullary.

Dynamics of cerebral edema. The role of an intact vascular bed in the production and propagation of vasogenic brain edema.

Brain edema was produced in cats by a standardized cortical freezing lesion. With a careful microsurgical tehnique, the injured cortex was removed as a single piece, either immediately after induction or at 2, 4, or 8 hours after lesion production. The injured brain was either discarded or replaced in its bed. Brain edema and the defect in the blood-brain barrier were assessed by determining percent dry weight, increase in volume of white matter, and spread of Evans' blue by planimetry. The results indicate that 1) if the lesion is removed immediately after production, formation of the expected vasogenic brain edema is completely abolished; 2) replacement of the frozen brain is unable to induce significant increase in permeability of the surrounding blood-brain barrier or a significant amount of brain edema; and 3) if the lesion is removed at 2, 4, or 8 hours with or without replacement, advancement of the edema front and increase in the amount of edema is stopped. It appears that an intact vascular bed is necessary for the extracellular fluid component of brain edema, and that no edemagenic factors exist within the injured brain in this model that influence either the production or propagation of the increased extracellular fluid volume.

Dibutyryl cyclic adenosine 3',5'-monophosphate: its role in regulation of cat brain extracellular fluid.

The role of dibutyryl cyclic adenosine 3',5'-monophosphate (db cAMP) in influencing the water content of the cat's gray and white matter was evaluated by intracoritcal injection of 20 micrio L of 2 x 10(-1) to 2 x 10(-6)M solution of db cAMP. Cholera toxin, a stimulator of adenylate cyclase, also was tested. Concentrations of db cAMP less than 10(-3)M failed to produce significant change in brain water content, while concentrations greater than 10(-2)M produced 31.5% +/- 8% and 17.3% +/- 3.6% increases in white matter volume, respectively (P less than .05). Cholera toxin did not increase brain water levels. These results are discussed in relation to the pathophysiology of brain edema.